Provider Demographics
NPI:1568542173
Name:GWIN, JOHN R (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:GWIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 N TOWNSHIP RD
Mailing Address - Street 2:
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-9192
Mailing Address - Country:US
Mailing Address - Phone:740-501-5577
Mailing Address - Fax:
Practice Address - Street 1:5180 E MAIN ST
Practice Address - Street 2:SUITE F
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2436
Practice Address - Country:US
Practice Address - Phone:614-866-9002
Practice Address - Fax:614-866-3581
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5311-T2220152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2373828Medicaid
OHU94172Medicare UPIN
OH2373828Medicaid
WV4101725Medicare PIN
OH4101724Medicare PIN
OH4101723Medicare PIN